CMS-P-0015A Prescribed Medicine Utilization

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

Question Type

PMQ- PRESCRIBED MEDICINE UTILIZATION

Question Text/Description

Code List

Routing

PRESCRIBED MEDICINE UTILIZATION QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007, C010
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
If INTTYPE in(C001, C002, C004, C005, C006, C007) AND SEASON=WINTER, administer after ACQ.
If INTTYPE in(C001, C002, C004, C005, C006, C010) AND SEASON =SUMMER/FALL, administer after MPQ.

[Now let’s talk about prescribed medicines [you have/(SP) has] obtained since (REFERENCE
DATE/UTILDATE).]
PMINTA

PMINTROA

no entry

PM1 - PMFILLED

[While talking about medical visits, you mentioned some medicine(s): [READ MEDICINE NAME(S) BELOW.]]
[Now I’d like to talk about prescribed medicines.]

PMFILLED

PM1

yes/no

[Besides that medicine, /Besides those medicines, ] [(Since/since) (REFERENCE
DATE/UTILDATE)/(Between/between) (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)] [have you had/has (SP) had/did (SP) have] any (other) prescriptions
filled?
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT, WHEN
IT WAS OBTAINED, WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND WHETHER OR NOT
THE RESPONDENT ACTUALLY TOOK THE MEDICINE.]

BOX PM1

PM1PMMEDS

GETPMMEDS

routing

no entry

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

(01) BOX PM1
(02) PM3 - PMREFILL
(-8) PM3 - PMREFILL
(-9) PM3 - PMREFILL

IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT
ROUND, GO TO GETPMMEDS - PM1PMMEDS.
ELSE GO TO PM2 - MEDICINE_PM1.

It would be helpful if I could look at any medicine bottle(s), container(s), or bag(s) that you have so that I can
spell the medicine name correctly and enter the strength of the medicine. [Also, please take out [your/(SP's)]
(MEDICARE PRESCRIPTION DRUG PLAN NAME) medicine statements, which should have that same
information on them.]

BOX PM2

[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same information for all of the medicines [you/(SP)]
obtained since the last interview, if you’d like to get those bottles, too.

BOX PM2

routing

IF THERE IS AT LEAST ONE MEDICINE FROM A PRIOR ROUND ON THE EVENT TABLE FOR THIS CASE,
GO TO MEDICINE_PM1-MEDICINE_PM1.
ELSE GO TO PM2B-PMBOTTLE.

Page 1 of 7

2021 MCBS Community Questionnaire

Variable Name

MEDICINE_PM1

MR Screen Name

Question Type

PMQ- PRESCRIBED MEDICINE UTILIZATION

Question Text/Description

MEDICINE_PM1

code one

What is the name of the medicine?

BOX PM3

routing

IF THIS MEDICINE HAS AN EXACT MATCH TO THE FDB LIST ( PMEDID^=.), THEN GO TO PM2ASAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.

Code List

Routing

[DISPLAY MEDICINE ROSTER AS RESPONSE
OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
BOX PM3
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME, STRENGTH, FORM, AND
QUANTITY FOR EACH.

CODE "YES" WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM,
STRENGTH AND AMOUNT ARE EXACTLY THE SAME AS IN THE PREVIOUS INTERVIEW.
At the time of the last interview, [you/(SP)] purchased (MEDICINE NAME) in the form of (MEDICINE FORM).
The strength was [MEDICINE STRENGTH].
SAMEFSAM

SAMEFSAM

yes/no
The amount in the container when it was obtained was (PREVIOUS ROUND MEDICINE AMOUNT).

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

BOX PM4

(01) YES
(02) NO
(03) NO BUT R CAN ANSWER QUESTIONS
(-8) DON'T KNOW
(-9) REFUSED

(01) MED-PMEDNAME
(02) PMKNWNM-PMKNWNM
(03) MED-PMEDNAME
(-8) PMKNWNM-PMKNWNM
(-9) PMKNWNM-PMKNWNM

Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS FORM, STRENGTH, AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.

PMBOTTLE

BOX PM4

routing

IF SAMEFSAM=1/YES, THEN DO NOT CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO GETNUMGETNUM.
ELSE, CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM2B-PMBOTTLE.

PMBOTTLE

code one

CODE “YES” WITHOUT ASKING IF BOTTLE, CONTAINER, BAG, STATEMENT, OR RECEIPT IS PRESENT.
Do you have the medicine bottle, container or bag, or Prescription Drug Plan Statement available?
IF R DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF R CAN ANSWER QUESTIONS
ABOUT THE FORM, STRENGTH, AND QUANTITY OF THE MEDICINE.

TO USE THE MEDICINE LOOKUP, START TYPING THE MEDICINE NAME IN THE PRESCRIBED MEDICINE
LOOKUP BOX. CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.

PMEDNAME

MED

lookup

ONCE YOU HAVE ENTERED ALL DETAILS FOR A MEDICINE, IF YOU NEED TO GO BACK AND CORRECT,
USE THE GREEN “RETURN TO PRESCRIBED MEDICINE LOOKUP” BUTTON.
[MEDICINE NAME SELECTED FROM LOOKUP OR
MANUALLY TYPED]

[PRESCRIBED MEDICINE LOOKUP TOOL]

PMBRNAME

MED

lookup

[PM BRAND NAME]

PMGNNAME

MED

lookup

[PM GENERIC NAME]

PMFORMFD

MED

lookup

Medicine Form [FDB LIST FORM NAME]

Page 2 of 7

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

Question Type

PMQ- PRESCRIBED MEDICINE UTILIZATION

Question Text/Description

Code List

Routing

(01)-(12) MED-PMSTRNFD
(91) MED-PMFORMOS
(-8) MED-PMSTRNFD
(-9) MED-PMSTRNFD

PMFORMMC

MED

code one

Medicine Form [MCBS FORM]

(01) PILLS (TABLETS, CAPSULES)
(02) LIQUID (TO BE TAKEN ORALLY)
(03) DROPS (EYE/EAR/NOSE)
(04) OINTMENT, CREAM, LOTION (TOPICAL OR
INTERNAL)
(05) SUPPOSITORIES
(06) AEROSOL/SPRAY, INHALANT, SOLUTIONS,
DISKUS
(07) SHAMPOO, SOAP
(08) INJECTION
(09) IV INJECTION
(10 PATCHES
(11) GEL OR JELLY (TOPICAL OR INTERNAL)
(12) POWDER, GRANULES
(91) OTHER
(-8) Don't Know
(-9) Refused

PMFORMOS

MED

verbatim

[MEDICINE FORM OTHER SPECIFY]

(01) CONTINUOUS ANSWER

PMFORMFN

MED

verbatim

[FINAL CONCATENATED MEDICINE FORM]

PMSTRNFD

MED

verbatim

Medicine Strength

(01) [MEDICINE FORM SELECTED FROM LOOKUP]
(-7) NOT FOUND
(-8) DON'T KNOW

STRNNUMBB

MED

numeric

Medicine strength number

(01) CONTINUOUS ANSWER

STRNUNIT

MED

code one

PMSTRNOS

MED

verbatim

[MEDICINE STRENGTH UNIT OTHER SPECIFY]

PMSTRUNI

MED

ookup

[FINAL CONCATENATED MEDICINE STRENGTH]

PMEDID

MED

numeric

[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH
THE LOOKUP. IT IS HIDDEN ON SCREEN.]

FAMILYID

MED

numeric

[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES BY NAME ONLY,
EXCLUDING STRENGTH AND FORM, THROUGH THE LOOKUP. IT IS HIDDEN ON SCREEN.]

Medicine strength unit

(01) MICROGRAMS (mcg, mc)
(02) MILLIGRAMS (mg)
(03) GRAINS (gr)
(04) MILLIEQUIVALENTS (meq)
(05) GRAMS (g, gm)
(06) PERCENT (%)
(07) INTERNATIONAL UNITS (IU)
(08) UNITS (U)
(91) OTHER
(-8) Don't Know
(-9) Refused

(01)-(08) MED-MEDID
(91) MED-PMSTRNOS
(-8) MED-PMEDID
(-9) MED-PMEDID

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2021 MCBS Community Questionnaire

PMQ- PRESCRIBED MEDICINE UTILIZATION

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

PMKNWNM

PMKNWNM

code one

DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?

(01) YES
(02) NO
(-9) REFUSED

(01) MED-PMEDNAME
(02) PMCOND-PMCOND
(-9) PMCOND-PMCOND

(01) ALLERGY MEDICINE
(02) ALZHEIMERS
(03) ANTIBIOTICS
(04) ANTIPSYCHOTIC
(05) ASTHMA OR COPD
(06) BLOOD PRESSURE
(07) CHOLESTEROL
(08) COUGH AND COLD MEDICINE
(09) DEPRESSION
(10) DIABETES
(11) DIURETICS (WATER PILLS)
(12) EAR DROPS
(13) ESTROGEN
(14) EYE DROPS OR PREPARATION
(15) NASAL SPRAY/DROPS
(16) OSTEOPOROSIS (BONE LOSS)
(17) PAIN MEDICINE
(18) STEROID (GLUCOCORTICOID)
(19) STOMACH ACID OR ULCER
(20) OTHER
(-8) DON'T KNOW
(-9) REFUSED

(01)-(19) GETNUM-GETNUM
(20) PMCOND-PMCONDOS
(-8) GETNUM-GETNUM
(-9) GETNUM-GETNUM

What condition is this medicine prescribed for or what is its primary use?
PMCOND

PMCOND

code one
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.

PMCONDOS

PMCOND

verbatim

OTHER (SPECIFY)

How many times [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)] did [(you/(SP)] obtain (MEDICINE NAME)]]?
GETNUM

TABNUM

GETNUM

numeric

[IF THE MEDICINE WAS ENTERED IN ERROR AND WAS NOT OBTAINED IN THE CURRENT ROUND,
CHECK “ENTERED IN ERROR” AND LEAVE THE BOX BLANK WHERE YOU ENTER THE NUMBER OF
REFILLS.]

BOX PM5

routing

IF GETNUM=996/EVENT ENTERED IN ERROR OR PMKNWNM=02/NO OR SAMEFSAM=1/YES, GO TO
PMMORE-PMMORE;
IF SAMEFSAM=1/YES AND PMFORMFN=pills (tablets, capsules), GO TO PM12-TABSADAY;
ELSE IF MEDICINE FORM IS PILLS, TABLETS OR CAPSULES [PMFORMMC=1 OR PMFORMFD CONTAINS
("PILL", "TAB", "CAP") GO TO TABNUM-TABNUM;
ELSE GO TO PM16-AMTUNIT.

TABNUM

numeric

HOW MANY PILLS, TABLETS, OR CAPSULES WERE IN THE CONTAINER WHEN IT WAS OBTAINED?

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

(01) continuous answer
(996) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused

BOX PM5

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW

BOX PM6

Page 4 of 7

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

Question Type

PMQ- PRESCRIBED MEDICINE UTILIZATION

Question Text/Description

Code List

Routing

(01) PM16 - AMTNUM
(02) PM16 - AMTNUM
(03) PM16 - AMTNUM
(04) PM16 - AMTNUM
(05) PM16 - AMTNUM
(06) PM16 - AMTNUM
(07) PM16 - AMTNUM
(91) PM16 - AMTUNOS
(-8) BOX PM6

AMTUNIT

PM16

quantity unit

HOW MUCH MEDICINE WAS IN THE CONTAINER WHEN IT WAS OBTAINED?
[PLEASE ENTER THE AMOUNT IN THE CONTAINER, NOT THE STRENGTH OF THE MEDICINE.]

(01) OUNCES (oz)
(02) GRAMS (g, gm)
(03) MILLILITERS (ml, cc)
(04) MILLIEQUIVALENTS (meq)
(05) MILLIGRAMS (mg)
(06) MICROGRAMS (mcg)
(07) PUFFS, DOSES, BLISTERS
(91) OTHER
(-8) DON'T KNOW

AMTUNOS

PM16

text

OTHER (SPECIFY)

(01) CONTINUOUS ANSWER

PM16 - AMTNUM

AMTNUM

PM16

numeric

(01) CONTINUOUS ANSWER

BOX PM6

BOX PM6

routing

IF PRESCRIPTION MEDICINE FORM IS PILLS, TABLETS OR CAPSULES, GO TO PM12 - TABSADAY.
ELSE GO TO BOX PM7.

HOW MANY PILLS, TABLETS, OR CAPSULES ARE PRESCRIBED TO BE TAKEN IN A DAY?

TABSADAY

PM12

numeric

TABSADAY95

PM12

code one

IF LESS THAN ONE UNIT IS TO BE TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX:
HALF A PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TO BE TAKEN “AS NEEDED,” ENTER THE MAXIMUM AMOUNT THAT IS TO BE TAKEN IN (01) CONTINUOUS ANSWER
A DAY AND SELECT "TAKE AS NEEDED".
FOR MEDICINES TO BE TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER
DOSING INSTRUCTIONS".
IF THE AMOUNT TO BE TAKEN PER DAY IS NOT CLEAR OR NOT INDICATED, SELECT "DON'T KNOW".

PM12 - TABSADAY95

(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) Empty

PM13-TABTAKE

(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW

PM13 - TABTAKE96

(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY

BOX PM7

How many pills, tablets, or capsules (do/did/does) [you/(SP)] usually take in a day?
[READ IF NECESSARY: This question is asking about how often you actually take the medicine, not how often
the medicine is prescribed to be taken.]
TABTAKE

PM13

numeric
IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A
PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TAKEN “AS NEEDED,” SELECT "TAKE AS NEEDED".
FOR MEDICINES TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER
DOSING INSTRUCTIONS".

TABTAKE96

PM13

code one

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2021 MCBS Community Questionnaire

Variable Name

PMSATVA

PMSATHMO

PMQ- PRESCRIBED MEDICINE UTILIZATION

MR Screen Name

Question Type

Question Text/Description

BOX PM7

routing

IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR
ANY PREVIOUS ROUND), GO TO PMSATVA - PMSATVA.
ELSE GO TO BOX PM8.

PMSATVA

yes/no

Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department of
Veterans Affairs or V.A.?

BOX PM8

routing

IF SP COVERED BY A MEDICARE MANAGED CARE PLAN OR A PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO PMSATHMO - PMSATHMO.
ELSE GO TO PMMORE-PMMORE.

yes/no

Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) at [READ MANAGED CARE
(01) YES
PLAN NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN
(02) NO
NAME(S) BELOW]?
(-8) DON'T KNOW
(-9) REFUSED
[PROBE: This could include obtaining the purchases at a plan pharmacy; at a pharmacy that honors
[your/(SP’s)] plan card; or through a mail order service that the managed care plan referred [you/(SP)] to.]

PMSATHMO

([NO MEDICINES HAVE BEEN REPORTED FOR (SP) FOR THE CURRENT REFERENCE PERIOD/THE
NAMES OF ALL MEDICINES REPORTED FOR THE CURRENT REFERENCE PERIOD ARE DISPLAYED
BELOW.])
PMMORE

PM17

yes/no
[REVIEW THE INFORMATION BELOW WITH THE RESPONDENT. ASK, OR CODE AS APPROPRIATE IF R
ALREADY INDICATED: Are there any (more) medicines since (REFERENCE DATE/UTILDATE) that we haven't
talked about?]

People sometimes forget to mention refills of earlier prescriptions. (In addition to what you’ve told me about,
did/Did) [you/(SP)] have any prescriptions refilled [since (REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)]?
PMREFILL

PMREFILL

yes/no
[COUNT A MEDICINE AS "REFILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT,
WHEN IT WAS OBTAINED, WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND WHETHER
OR NOT THE RESPONDENT ACTUALLY TOOK THE MEDICINE.]

PMDRPHON

PMDRPHON

yes/no

People sometimes forget to mention prescriptions that were phoned in by a doctor. (In addition to what you’ve
told me about, did/Did) [you/(SP)] get any medicine prescribed by a doctor or other health professional in a
telephone call to a drugstore or pharmacy [since (REFERENCE DATE/UTILDATE)/between (REFERENCE
DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)]?
[INLCUDE ALL PRESCRIBED MEDICINES REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT,
WHEN IT WAS OBTAINED, WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND WHETHER
OR NOT THE RESPONDENT ACTUALLY TOOK THE MEDICINE.]

BOX PM4A

routing

IF SPALIVE=1 (ALIVE) AND SEASON=WINTER GO TO PMNOTGET-PMNOTGET. ELSE GO TO BOX
PMEND.

PMNOTGET

PMNOTGET

yes/no

Now thinking about all of last year, that is calendar year [CURRENT YEAR – 1], were any medicines prescribed
for [you/(SP)] that [you/he/she] did not get? Please include refills of earlier prescriptions as well as prescriptions
that were written or phoned in by a doctor or other health professional.

TEMPMED1

SC16

text

Code List

Routing

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

BOX PM8

PMMORE-PMMORE

(01) ADD ANOTHER
(02) ALL DONE

(01) BOX PM2
(02) PMREFILL - PMREFILL

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

(01) BOX PM2
(02) PMDRPHON - PMDRPHON
(-8) PMDRPHON - PMDRPHON
(-9) PMDRPHON - PMDRPHON

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

(01) BOX PM2
(02) BOX PM4A
(-8) BOX PM4A
(-9) BOX PM4A

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) SC16 - TEMPMED1
(02) BOX PMEND
(-8) BOX PMEND
(-9) BOX PMEND

(01) [Continuous answer.]

SC16 - TEMPMED2

[DISPLAY MEDICINE ROSTER]
What were the names of those medicines?
ENTER ALL MEDICINES.

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2021 MCBS Community Questionnaire

PMQ- PRESCRIBED MEDICINE UTILIZATION

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

TEMPMED2

SC16

text

What were the names of those medicines?
ENTER ALL MEDICINES.

(01) [Continuous answer.]
(-7) Empty

(01) SC16 - TEMPMED3
(-7) SCPMCODS -SCPMCODS

TEMPMED3

SC16

text

What were the names of those medicines?
ENTER ALL MEDICINES.

(01) [Continuous answer.]
(-7) Empty

(01) SC16 - TEMPMED4
(-7) SCPMCODS -SCPMCODS

TEMPMED4

SC16

text

What were the names of those medicines?
ENTER ALL MEDICINES.

(01) [Continuous answer.]
(-7) Empty

(01) SC16 - TEMPMED5
(-7)SCPMCODS -SCPMCODS

TEMPMED5

SC16

text

What were the names of those medicines?
ENTER ALL MEDICINES.

(01) [Continuous answer.]
(-7) Empty

SCPMCODS -SCPMCODS

(01) THOUGHT IT WOULD COST TOO MUCH
(02) DIDN'T THINK MEDICINE WOULD HELP
CONDITION
(03) WAS AFRAID OF MEDICINE
REACTIONS/CONTRAINDICATIONS
(04) DON'T LIKE TO TAKE MEDICINE
(05) DIDN'T THINK MEDICINE WAS NECESSARY
(06) NOT COVERED BY INSURANCE/NOT ON PLAN
FORMULARY
(07) TROUBLE OBTAINING MEDICINE
(08) OBTAINED/USED SAMPLES
(09) USED ANOTHER MEDICINE AS A
SUBSTITUTION
(91) (OTHER/SC17A - SCPMOTOS OTHER SPECIFY
TEXT)
(-8) Don't Know
(-9) Refused

(01) BOX SC2
(02) BOX SC2
(03) BOX SC2
(04) BOX SC2
(05) BOX SC2
(06) BOX SC2
(07) BOX SC2
(08) BOX SC2
(09) BOX SC2
(91) SCPMOTOS - SCPMOTOS
(-8) BOX PMEND
(-9) BOX PMEND

(01) [Continuous answer.]

BOX SC2

SHOW CARD PM1
This card lists some reasons people have given for not having prescriptions filled or refilled.
Which of these reasons explains why [you/(SP)] did not obtain the [READ MEDICINE(S) BELOW]?

SCPMCODS

SCPMCODS

code all

[MEDICINE 1 FROM SC16]
[MEDICINE 2 FROM SC16]
[MEDICINE 3 FROM SC16]
[MEDICINE 4 FROM SC16]
[MEDICINE 5 FROM SC16]
[PROBE: Any other reason?]
CHECK ALL THAT APPLY.

SCPMOTOS

SCPMMAIN

SCPMOTOS

verbatim text

OTHER (SPECIFY)

BOX SC2

routing

IF SCPMCODS - SCPMCODS INCLUDES MORE THAN ONE RESPONSE, GO TO SCPMMAIN - SCPMMAIN.
ELSE GO TO BOX PMEND.

SCPMMAIN

code 1

(01) THOUGHT IT WOULD COST TOO MUCH
(02) DIDN'T THINK MEDICINE WOULD HELP
CONDITION
(03) WAS AFRAID OF MEDICINE
Which of these was the main reason [you/(SP)] did not obtain [this medicine/these medicines] during (CURRENT REACTIONS/CONTRAINDICATIONS
(04) DON'T LIKE TO TAKE MEDICINE
YEAR)?
(05) DIDN'T THINK MEDICINE WAS NECESSARY
[READ REASONS BELOW IF NECESSARY.]
(06) NOT COVERED BY INSURANCE/NOT ON PLAN
FORMULARY
[MEDICINE 1 FROM SC16]
(07) TROUBLE OBTAINING MEDICINE
[MEDICINE 2 FROM SC16]
(08) OBTAINED/USED SAMPLES
[MEDICINE 3 FROM SC16]
(09) USED ANOTHER MEDICINE AS A
[MEDICINE 4 FROM SC16]
SUBSTITUTION
[MEDICINE 5 FROM SC16]
(91) (OTHER/SC17A - SCPMOTOS OTHER SPECIFY
TEXT)
(-8) Don't Know
(-9) Refused

BOX PMEND

routing

GO TO OMQ.

BOX PMEND

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